Max's Helping Paws Foundation · Application for Financial Assistance

CLIENT APPLICATION FOR SUPPORT

Which Program are You Applying to?

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Critical Care/Standard Program Eligibility

The Critical Care/Standard Program allows for Max's to provide financial support for treatment of your pet for up to $500 in diagnostics, up to 50% of necessary treatments to a maximum of $1,500.

ELIGIBILITY REQUIREMENTS

Your vet must provide you an authorization code
Pet owner must reside in Monterey County
Pet owners requesting above $500 must provide proof of income
Pet owners must provide copy of ID
Treatment must not have already taken place

Continued Care Program Eligibility

The Continued Care/Long Term Support Program allows for Max's to provide financial support for treatment of your pet for up to $500 in diagnostics, up to 50% of necessary treatments to a maximum of $6,000 for ongoing treatments for long term injury or illness over a two year period.

ELIGIBILITY REQUIREMENTS

Your vet must provide you an authorization code
Pet owner must reside in Monterey County
Pet owners requesting above $500 must provide proof of income
Pet owners must provide copy of ID
Treatment must not have already taken place

Chestnut Crisis Fund Program Eligibility

Chestnut's Crisis Fund allows for Max's to provide financial support for treatment of your pet for up to 75% of necessary treatments to a maximum of $2,500.

ELIGIBILITY REQUIREMENTS

Your treating veterinarian must provide you an authorization code
Pet owners must provide copy of ID
Pet owner must reside in Monterey County
Pet owners must be experiencing financial hardship due to an immediate reduction in wages from the impact of COVID 19 on their place of employment
Pet owners must provide ONLY ONE of these in order to receive support
- Letter from employer noting reduction or elimination of work due to COVID 19
- Submission of two consecutive pay stubs - one prior to March 13
- Copy of your application for Unemployment or government support
- Proof of employment prior to March 13 at business known publicly to have reduced hours or closure

Which Veterinary Practice will be doing treatment?

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Application Authorization Code Given To You By Your Treating Veterinarian

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PET OWNER & SPOUSE/PARTNER/PET CO-OWNER INFORMATION

Have you applied to Max's Helping Paws for support in the past?

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Yes

No

Owner Name (primary applicant)

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First Name

Last Name

Owner's Preferred Phone

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Owner's Email

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Picture of your driver's license (will be required for processing)

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You must submit either through form or by sending photo of your ID/DL to admin@maxshelpingpaws.org

Pet Co-Owner/Caretaker Name

First Name

Last Name

Pet Co-Owner/Caretaker Phone

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Pet Co-Owner/Caretaker Email

Address (please input NA on Address Line 2 if that does not apply)

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

How Many Adults Including Applicant Over 18 At this Address?

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How Many Children Under 18 At this Address?

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Check any that apply to you

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Disabled

Senior (65+)

Veteran

Unemployed

Active Military

Student

Homeless

None of the Above

Check any that applyto Pet Co-Owner/Caretaker

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Disabled

Senior (65+)

Veteran

Unemployed

Active Military

Student

Homeless

None of the Above

Proof of Government Program Participation

PET INFORMATION

Pet's Name

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Type Of Pet

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Pet's Age

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Pet's Gender

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Pet's Breed or Breeds if Mix

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Please upload a Cute, Clear, CLOSE UP photo of your pet

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Is This Pet Current On Rabies And DHPP Vaccines?

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Is This Pet Spayed/Neutered (also referred to as FIXED)

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Why not spayed or neutered?

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Where Did You Get This Pet?

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How Long Have You Had This Pet?

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How Many Other Pets Are In Your Home?

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When Did This Pet Last See A Vet Before this issue arose?

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Name Of The Primary Vet Clinic where preventative care is received (And Name Records Are Under)

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(If you do not have a regular veterinarian, explain why not here)

What Problem Is Your Pet Currently Experiencing And Why Are You Applying For Assistance? Provide as much detail as possible

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How Did The Injury/Illness Occur If Known?

Is Pet At Treating Veterinary Practice Now?

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HOUSEHOLD FINANCIAL INFORMATION

Have You Applied to Care Credit?

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You must submit results from Care Credit Application in order to be considered

Yes

No

Please upload a copy or phone picture of Care Credit results (required for processing)

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HOUSEHOLD FINANCIAL INFORMATION

Owner's Employer Name

Owner's Employer's Phone Number

Pet Co-Owner/Caretaker Employer Name

Pet Co-Owner/Caretaker Employer Phone Number

Do You Rent Or Own Your Home?

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Rent

Own

Neither

Monthly Rent Or Mortgage ($)

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Combined Gross Monthly Income For Household ($)

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Please upload a copy of last month's bank statements if requesting more than $500

Please upload recent pay stub

File Upload #1 Pre COVID Proof of Income

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(see accepted options noted in application)

File Upload #2 Post COVID Proof

How much support are you requesting? (CANNOT EXCEED 1500)

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How much support are you requesting? (CANNOT EXCEED 2500)

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Cost Estimate from Treating Veterinarian

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How much can you contribute to your pet's care? (AMOUNTS ONLY, i.e. 200)

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Please note we are not pay the entire cost of treatment. As a pet owner you are expected to incur some costs for the care of your pet.

Who else have you requested financial assistance or formally applied to?

Friends, family members, other non profits

Do you receive any of the following? (Check all that apply)

CalWorks/CalFresh

PG&E Reach/PG&E Care

Medi-Cal

CHIP

Disability

Social Security

AT&T Lifeline

Please Let Us Know Anything Else About Your Pet Or Your Situation That Will Help Us Make A Determination About Your Request

I UNDERSTAND AND AGREE THAT:

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If approved, Max's Helping Paws provides funding for up to 50% of the bill (up to a maximum of $1500.)

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If approved, Max's Helping Paws provides funding for up to 75% of the bill (up to a maximum of $2500.)

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If I have Care Credit or Scratch Pay funds, I may be asked to use most or all available credit towards the pet's treatment unless I show documentable need to use it elsewhere, or documentable inability to pay it back each month.

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Pets that receive MHPF funding must be spayed or neutered unless there is a medical or professional reason. If my pet is not spayed/neutered at the time funding is given, I agree to have my pet spayed/neutered at my own expense within a set time frame determined by my treating veterinarian.

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MHPF may ask other funding sources to assist in paying for the veterinary care needed and I hereby consent, in connection with my request for financial assistance from MHPF , to MHPF providing any and all financial, personal and credit information that I provide to MHPF to other potential funding sources.

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In order for MHPF to continue helping pets like yours, telling your story for fundraising purposes is essential. As a condition of acceptance of financial assistance, you agree to allow MHPF to interview you and request photos to be used for fundraising purposes. Follow-up after recovery is a requirement of this grant.

I accept and approve the above. If I receive assistance, I consent to use of my pet’s name, image & story by MHPF for website, PR, and other marketing purposes, AND I will cooperate with MHPF to schedule photos, interviews or video as necessary for their use.

Owner "Signature" (Type Name)

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